On the front lines

Primary care forms the bedrock of the U.S. health care system, but external elements threaten erosion. According to the federal Agency for Healthcare Research and Quality, “the U.S. primary care system is struggling under increasing demands and expectations, diminishing economic margins and increasing workforce attrition compounded by diminishing recruitment of new physicians… into primary care.”

The physicians who face them on a daily basis acknowledge these pressures, but most are driven by a commitment to their patients and to the field that supersedes all else. Alumni News recently invited Medical College alumni in primary care to tell us about their practice and its importance in the community. These conversations form the basis of Profiles in Primary Care.

In our first installment of this multi-part series, some alumni on the front lines of medicine share their experiences, their challenges and their inspirations in primary care.

She’s on pace to see it all. Chain saw lacerations. Ascaris in a baby’s diaper. Amputated digits from snowblower mishaps. Cases of ALS and Henoch-Schonlien purpura. (The small town doctor credits pictures that once hung in the Medical College of Wisconsin lecture hall with her ability to diagnose the latter). Vernette Carlson, MD ’84, GME ’86, even keeps in her office a box of “treasures” consisting of foreign objects she has removed from her patients.

Vernette Carlson, MD ’84, GME ’86, is a solo practitioner in the Upper Peninsula of Michigan.

For more than 27 years, Dr. Carlson has practiced family medicine in Michigan’s rural Upper Peninsula. Her family has lived in Menominee County for four generations. She graduated high school there and now is a solo practitioner in Stephenson. And according to research commissioned by the Agency for Healthcare Research and Quality, she is one of approximately 209,000 practicing primary care physicians in the United States.

Dr. Carlson’s stories are unique, but many of the themes would be familiar to her peers across the nation. The business of primary care may sometimes feel like a yoke around the practice of primary care, but the rewards can come in many forms.

“The main challenge is payer mix and reimbursement,” said Dr. Carlson, who sees about 54 percent Medicare patients. “I am very concerned that an area like this will not be able to sustain a physician in the future. I am able because I have had a very large, very loyal practice for so many years.”

The personal relationships in a rural family practice generate that type of loyalty. Dr. Carlson has patients who sometimes come straight to her house for care. It’s not unusual either for her patients to receive a handwritten note of concern. As an independent doctor, she also takes pride in being able to “treat patients the way I would like to be treated,” by maintaining control over charges, staffing, specialist referral and insurance plan affiliation.

Dr. Carlson is the medical director of the local nursing home and has even been involved with medical research. After she identified the first case of Lyme disease in Michigan, she teamed with the Michigan Department of Health and the Centers for Disease Control and Prevention to publish two articles in professional journals and speak on the subject. She appreciates the great variety of primary care and believes in the model.

“Primary care is very cost effective for society, as patients have so many fewer hospitalizations when we can head off exacerbations of chronic diseases like CHF and COPD,” she said. “Also, we help patients and families avoid a lot of overly aggressive management with end of life decisions.”

Knowing patients well and following them over time is the hallmark of a primary care physician, especially in a good medical home, said Larissa Malmstadt, MD ’04, GME ’07. A pediatrician who began her career in rural Maine, Dr. Malmstadt has practiced in Greenfield, Wis., with Children’s Medical Group, affiliated with Children’s Hospital of Wisconsin, since 2009.

“From a social standpoint, a child’s pediatrician can shape the health and well-being of the entire family through the care and education given and the relationship they build,” she said. “From a purely economic standpoint, building trust between the doctor and the family can help with referral management and decrease unnecessary use of emergency rooms, limiting waste of health care dollars.”

Although Dr. Malmstadt is in a suburban clinic, her patient population is reflective of the central city. She speaks Spanish half of her day and works extensively with the foster care system. Giving back to the community in which she grew up was her foremost motivation during medical school. Even though she has the full support of her group and practice partners, her goals are not without obstacles.

“By far, the most challenging thing for me is balancing the business side of my practice with giving the best medical care possible to my patients,” said Dr. Malmstadt, who is committed to keeping her practice open to Medicaid patients. “With the constraints I have from insurance companies and limitations based on the time I am able to spend with each individual family during the workday, I am often left with the desire to be able to do more, more quickly and more completely.”

Despite the pressures, she draws inspiration from a simple joy: The kids.

Mark W. Sharon, MD ’79, performs an exam.

Caring for families has that attraction. Mark W. Sharon, MD ’79, has spent 30 years in the eastern Wisconsin town of Plymouth as a family physician. The people, their work ethic and community pride have made it easy to call Plymouth home for three decades. Similar incentives have kept him engaged in full-time primary care throughout his career.

“First are the long-term relationships I have developed with many families in the area,” he said. “In many cases I have provided medical care for up to five generations over the years. Second, I have been blessed with excellent partners in family medicine. This has allowed me the flexibility to return to MCW in 1998 to learn gastrointestinal endoscopy, also to compete in 10 worldloppet cross-country ski races in the USA, Canada and eight European countries.”

Dr. Sharon’s clinic is a branch of the Aurora Sheboygan Clinic and includes six family physicians, a general internist and two physician assistants. He finds the greatest challenge to be in his group’s endeavor to demonstrate quality of care. The initiative measures group and individual performance in areas addressed daily in a primary care office, including the management of disease states like diabetes and hypertension as well as preventive screenings such as mammography and colonoscopy. Continuity of care and wellness are among the benefits of a strong primary health care system.
“I believe primary care is important today for the very reasons that the specialty of family medicine was developed over 40 years ago,” Dr. Sharon said. “At that time, much like today, medical care was fragmented, impersonal, overspecialized and overpriced. Hopefully, with health care reform, there will come a true emphasis on prevention and health maintenance. That will happen only through a strong base in primary care.”

Mary E. Arenberg, MD, GME ’83, and George Schroeder, MD, GME ’82, have practiced family medicine together for almost 30 years.

Plymouth, Wis., is also home to a husband and wife who together have maintained a private family practice there for more than 27 years. Mary E. Arenberg, MD, GME ’83, and George Schroeder, MD, GME ’82, came to Plymouth after six months in central Washington and a year at a mission hospital in West Africa. Success has required enduring the loss of their local hospital and navigating the challenge of “providing continuity of care in a system that, despite lip service to the contrary, relegates family medicine to the back burner,” Dr. Arenberg said.

Through participation in a research group, however, Dr. Arenberg and Dr. Schroeder are contributing to the improvement of primary health care, which has also benefitted their patients through disease prevention, reduced end-stage disease and fewer hospitalizations. Early adopters of an electronic medical records (EMR) system, Dr. Arenberg and Dr. Schroeder joined Practice Partner Research Network (PPRNet), which collects data from the common EMR systems of multiple primary care practice sites nationwide to conduct prospective studies on disease management, screenings, immunizations and other aspects
of care.

Each of the projects improved the quality of their care on that particular topic, they said. They also gained an appreciation for auditing large portions of their work, which allows them to perpetually transform their practice.

“Through these audits, we are able to stand back and examine our practice in a manner otherwise impossible,” Dr. Arenberg said. “We are then able to modify our behavior and improve our practice’s performance. With the aid of the EMR and our research network, we are developing a quality of care that our health care system desperately needs. At a time when American medicine is abandoning primary care, casting about for other means to provide quality yet control runaway cost, this primary care research gives us a reference point that we can respect and relate to in family medicine.”

Ultimately, nothing can replace the continuity that results when primary care is supported by evidence-based guidelines to build long-term relationships between providers and patients, the doctors said.

That extended knowledge of patients and their needs gives primary care its value, according to another couple who practice together in the rural-industrial community of Medford, Wis. Cathy Reuter, MD ’92, is a pediatrician, and Mark Reuter, MD ’92, is a family practitioner; they both work for Memorial Health Center Clinics-Medford.

“Rural areas are a great place to raise children and practice medicine,” said Cathy Reuter, who has practiced in Medford with her husband for 17 years. “You become part of the community and you know your patients, which makes it rewarding.”

Physician supply in the rural area contributes to the challenges of primary care practice, and recruiting colleagues can be difficult, she said.

“When physicians leave, the call significantly increases,” she said. “In addition, at times, managing difficult cases can be challenging since specialists are an hour away. You do, however, get to treat everything.”

Treating everything has characterized the primary care practice of Barbara A. Hummel, MD ’88, GME ’89, an independent family physician who provides comprehensive care to all ages. She has been in solo practice in West Allis, Wis., since 1997.

“I still do prenatal exams and follow patients into nursing homes,” she said. “I care for newborns in the hospital and follow them in my practice after discharge from neonatal care. I still do home visits and home hospice care.”

Dr. Hummel also gives a voice to primary care through medical societies. She is Vice Chair of the Wisconsin Medical Society Board, a member of the Governing Council for the American Medical Association (AMA) Senior Physician Group and Secretary of the Private Practice Congress of the AMA, in addition to being a past president of the Medical Society of Milwaukee County and a past director of the Wisconsin Academy of Family Physicians board.

Advocating for strength in primary care is in the interest of many Americans considering it represents the majority of patient visits. According to National Center for Health Statistics data, more than 51 percent of the nearly 956 million visits that Americans made to office-based physicians in 2008 were to primary care physicians.

The volume may be high, but physicians say they value each individual connection.

“Probably the part I love the most is that so many people call me by my first name, feel free to come up to me in the little, local restaurants, grocery store, church and school,” Dr. Carlson said. “This took some years to get used to, but it doesn’t reflect rudeness or dishonor but really is a sign of trust, friendship and genuine need.”

Looking ahead

The next installment in the Profiles in Primary Care series will feature alumni whose primary care practices encompass special populations.

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